A Call to Arms (and Legs) in the Civil War and in the Iraq War

Kate Daloz received an MFA from Columbia where she also taught undergraduate composition. Her most recent essay, "The Dowser Dilemma," was published in the Spring 2009 issue of The American Scholar. For more on medicine and war, please visit www.laphamsquarterly.org.

War drives innovation, in medicine as in weaponry. Those wounded in war stand at the crux of this ironic confluence, of technology designed to kill, and technology designed to heal. In the current wars being fought by the US in Iraq and Afghanistan, the innovations in killing aren't even particularly high-tech. Homemade Improvised Explosive Devices (IEDs) triggered by remote control can be disguised as an oil barrel or a pile of trash. A dead dog could explode with a force strong enough to send a seventeen-ton armored vehicle flying into the air. To a soldier on foot, even an overlooked soda-can could hide a deadly threat. IEDs account for more than seventy percent of the casualties to US troops in Iraq and Afghanistan. In an explosion, body armor protects the core with its vital organs, but leaves the extremities vulnerable. Thanks to high-tech field hospitals and speedy evacuations, US troops stand a better chance of surviving grievous injury than they ever have before -- but the injuries they sustain are also newly terrible.

The American war most often associated with a large number of veteran amputees is the Civil War. Between 1861 and 1865, at least 30,000 soldiers on the Union side alone lost a limb. Amputation accounted for three-quarters of all surgeries performed in field hospitals where doctors sometimes worked for days on end while discarded arms and legs piled up beside them.

Despite the fact that overworked Civil War surgeons often operated on dozens of patients in a row without cleaning their instruments, spreading lethal infections as they went (germ theory was just a few short decades away from being fully understood), the staggering number of amputations represented the best practices of the day. Though soldiers on both sides used a wide variety of weapons, one of the most common was also the most destructive: the minie ball was a soft-lead bullet, which expanded on impact, shattering bone and leading to devastating injuries, on a scale never before seen.

Veterans on crutches or with one neatly pinned-up sleeve soon came to be a hallmark of the Civil War. Philadelphia's South Street Hospital was so dedicated to serving amputee war veterans that its patients soon nicknamed it the "Stump Hospital." One regular visitor there was neurologist Silas Weir Mitchell who interviewed hundreds of wounded soldiers and used the information he gathered to make some of the first clinical diagnoses of what we now know as traumatic brain injury.

In response to the huge number of veteran amputees, the federal government awarded research grants for new innovations in prostheses. Between 1861 and 1873, 133 patents were issued for artificial limbs, crutches, and wheelchairs, up almost three hundred percent from the period before the war. The focus was on making them comfortable and workable, but also as lifelike as possible. "In our time, limb-making has been carried to such a state of perfection that both in form and function they so completely resemble the natural extremity that those who wear them pass unobserved and unrecognized in walks of business and pleasure," wrote one doctor in 1871.

Imagine what he would say if he could see the sleek metal crescents that recently caused controversy by allowing an amputee-athlete to outstrip his "able-bodied" opponents. While the nineteenth century saw many innovations in false legs, upper-body prostheses never went much further than lifelike hands made of India-rubber (an improvement over wood), and specialized variations that replaced the classic hook with forks, saws, and other tools. And, in contrast to the breathtaking breakthroughs in lower-body prostheses, there have not been many improvements in the decades since. Until now.

Since 2003, American soldiers in Iraq and Afghanistan have been losing limbs at twice the rate of any previous American war. More than six percent of injured US troops require amputation, in contrast to the three percent wounded during other wars. While the actual numbers are nowhere near even Vietnam War figures, what makes the current situation unprecedented is the ratio of amputations to deaths: for every four soldiers killed, one loses a limb--in Vietnam, it was one to eleven. Military hospitals found themselves ill equipped to handle the influx of amputees returning from Iraq and Afghanistan. Plans to renovate the aging Walter Reed Army Medical Center in Bethesda, Maryland were quickly revised to include an entire wing devoted to rehabilitation and state-of-the-art orthopedics

As it was after the Civil War, the newest wave of prosthetic research is being driven by the needs of young veteran-amputees and funded by government grants for research. For the first time, computer chips and wireless technology are being used to create extremely mobile "robot" hands which can pinch, grip and flex. Some have sensors which pick up minute signals from nerves and can move in response to thought. Dean Kamen, inventor of the Segway, announced last month that his "Luke arm" (named after Luke Skywalker's robotic hand) was ready for clinical trials. The arm, made from aluminum and packed with complex electronics, is light enough to be worn by a medium-sized woman and could be cased inside a silicone mold, specially customized to match its wearer's body.

But no matter the technological wonders, there's no replacement for an intact body. As one nurse wrote in 1871, echoing Lincoln, "A hand, a foot or an eye is, next to life, the most precious sacrifice which can be laid on any alter. To lose in life's morning one of these inestimable possessions, to go through life deprived of the cunning of the right hand or the exceeding service of the foot or the eye, is, no doubt, a great calamity."